It’s Not Just An Earache
That I Have
By Lee Hewitt

I teach English as a Second Language at the Adult Learning Program, (ALP) a community-based center in Jamaica Plain, a multiethnic section of Boston. The curriculum that I develop in my classrooms evolves from concerns and issues that are critical to the students’ lives. Health has always been a key issue for the ESL learners in my classes. However, I had never dealt with breast and cervical cancer, pap smears, mammograms and breast self-exams before.

I was really unsure how to approach this subject or how receptive students would be to exploring this aspect of health. Also I was going to develop and work with this curriculum in a mixed classroom. The students were men and women ranging from ages twenty-one to fifty. They were Vietnamese, Chinese, Cape Verdean, Dominican, Mexican, El Salvadorean and Puerto Rican. I had many concerns and a nervous edge of fear when I first thought of addressing these issues in the classroom. How would I get onto the subject of breast and cervical cancer? How would I deal with the potentially embarrassing aspects? What information did I need to know before I began? Would students want to explore this topic at all? Was this even a good topic for an ESL class? These questions and many others tumbled through my mind. And what was that feeling of fear all about?

Stepping through the fear
In talking with other teachers, in thinking about my initial response and the responses of my students to the topic of cancer, I have seen that fear creates a large barrier to addressing this health issue in the classroom. Why? Because cancer is scary!

Everyone has a cancer story: a close or distant relation who has suffered from cancer or they themselves have confronted cancer in their own bodies. Cultural attitudes towards cancer give it a great power. For example, a Chinese doctor in my class explained that in China if there was cancer in someone’s family, another family might choose not to let their child marry into that family because of the presence of that disease. The dreadful features of cancer - its pain, its unpredictability, its equation with death - all make cancer a magical Medusa-like disease.

So what must we do if we are going to deal with this health issue in the classroom? First off, we should own our fear because cancer is scary.
We are no longer talking about simple ear infections that can be treated with antibiotics for 10 days. However, because everyone does indeed have a cancer story, I found that there was a vibrant place for this health issue in the classroom. Students thanked me for talking about the subject. Students helped me step through any fear I had about dealing with this topic. In fact, I found that we stepped through the fear together.

A doctor who writes about healing, Gerald Jamplosky, talks about how “love is letting go of fear.” Love and caring can be the sources of your energy to talk about breast and cervical cancer and the actions we can take to detect them and take care of ourselves. This love and caring helped me let go of my fear and allowed my class to face this terrifying issue together. The informational brochures on cervical cancer, breast cancer, and Pap smears, mammograms and breast self-exam lie lifeless in the clinic waiting room. But those same brochures, augmented by dialogue, role plays, realistic diagrams of the body, and personal stories, take on a new life in the safe, sharing community that usually exists in the ESL classroom.

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Teacher Work: Getting Ready
I had the good fortune to be able to develop curriculum with the support of the Educational Literacy Initiative work and the help of my ESL student, Ramona Roberto. In the group, we read articles about breast and cervical cancer, Pap smears, mammograms and breast self-exams that helped us feel more prepared to deal with these topics in the classroom.

An equally important task for me was a survey that I did among my friends about mammograms and Pap smears (now I would include breast self-exams as well.) Had they ever had a mammogram? Had they ever had a Pap smear? What did their doctor tell them about it? The value of these interview were two-fold. I found out a lot about the kinds of myths that surrounded people’s understandings of these issues and tests, and got some practice talking about this pretty intimate health information with people.

The vocabulary of mammograms, Pap smears, breast cancer, and cervical cancer started to slip into my everyday conversation. I started to develop a fluency with this vocabulary before I dealt with it in the classroom. Also I found that people were quite willing to talk about these health issues.

Defining My Role, Defining My Goals
I also thought about my role in presenting this material in the ESL classroom. Because I am not a health educator or medical practitioner, I defined my role pretty narrowly. I didn’t need to know all about breast and cervical cancer. I wanted to know enough to handle basic questions and be able to help students sort through fact and myth about the diseases and the detection tests.

As a language teacher, I saw my role more clearly as providing vocabulary and basic health information about breast and cervical cancer and providing opportunities to practice language skills that would help students access the health services available in the United States. I wanted to give the students the tools they needed to get a Pap smear and a mammogram, to know more about breast self-examination, and to talk with their health practitioners more about all of this.

One concrete goal was to get women students in my class to the clinic for Pap smears and if needed mammograms and to start doing regular breast self-exams. Most important for the men and women in the class, I wanted to bring these issues into their everyday consciousness.

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“Good Health:” A Way In
Students in my class expressed a desire to learn about health. I knew I wanted to explore breast and cervical cancer but I was unsure how to bring it up. I decided I needed to know about the health practices of the students in my class before charging ahead with this topic.

I started off by exploring “good health.” What is it? What do people need to do to have good health? Were students’ lives healthier or not now that they were in the United States? What did people do to stay healthy? We explored nutrition and exercise; natural remedies and western medicines; culture shock; and some common adult and childhood illnesses. Students’ health vocabularies were growing and the health topic was expanding.

It was an excellent way to find out what students’ health habits and attitudes were. For example, did students see a regular check-up as part of a good health regimen? Were these students taking care of their own health needs as well as their children’s? What health “culture” did they have in their own families and communities?

Ramona Roberto explained the attitude and experiences of many of the Dominican students. “In our country people usually don’t go to the doctor for regular check-ups, only when they’re not feeling good especially the women when they are pregnant. However, hundreds of them even though they’re pregnant never go to the doctor and they have the baby at home.”

This presented a very different picture of health than the one that is compatible with getting regular Pap smears and mammograms. Many of the students explained that they come from countries where home natural remedies are by far the norm for health care and people don’t go to the doctor, clinic, or hospital unless they are experiencing a lot of pain. Many students explained that the poverty of their countries restricted the kinds of medicines and health care available to most people. From these explanations, it became clear that it is not necessarily just a lack of knowledge about Pap smears or mammograms that keep people from getting them: it is deeply rooted attitudes, experiences and health practices.

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Moving On To Cancer
We moved from good health to talking about cancer as a disease that affects all people. A brainstorming activity revealed that everyone knew what cancer was except one student who immediately understood when the word was translated into her first language. Everyone had ideas about what caused cancer, the different kinds of cancer and what we can do about it. In this initial exploration of what people can do about cancer, the discussion was general and did not involve such specifics as early detection.

Everyone had personal stories to tell. These were low intermediate students with a wide range of fluency skills, but they told wonderful stories in English about their friends, or their relatives experiences with cancer.

After this general discussion, we acted out a dialogue that Ramona and
I had written about two women and their experiences and concerns with breast cancer. This dialogue became the script of the photonovella.

Through this dialogue work, important attitudes surfaced. Students acknowledged that people often ignored their own health because they embraced the idea, “this will never happen to me.” Everyone found it difficult to find time to go to the doctor, especially if they didn’t have any pain. This made it necessary to explore the painless aspect of the early symptoms of breast cancer and cervical cancer. This was a pivotal informational point for many students. It awoke a fear that lurks within us all... “What if something is wrong and I don’t know it?” I believe that this fear was motivating and by the end of our breast and cervical cancer curriculum unit, five women from our class had gone to the clinic for long neglected checkups.

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Role Playing
We spent about a week and a half talking about cancer in general, then breast cancer, lumps, breast self-exam and mammograms. This is pretty heavy material, and I found that students had a breaking point that was important to observe. To ease the intensity of the cancer focus, at the end of the week we did role plays. For this activity, I wrote descriptions of three real-world situations in which the participants spoke with each other about health-related problems that I had heard students mention at different points during the unit. The students pair off, and each pair randomly picked an index card on which one of three situations was described. Each member of the pair then role-played one of the participants in the situation they had chosen, deciding what to say within the conversation I had set up.

These are three role-playing situations:

• You have a friend who is 35 years old. She hates going
to the doctor so she never gets a check-up. Tell your
friend why it is important to get a check-up.

• You are very sick. Call your boss and tell him why you
can’t come to work.

• Your best friend doesn’t want to do monthly breast self- exams. She thinks that they are stupid and embarrassing. Talk to your friend about breast self-exam. Tell her what you know. Tell her your opinion about doing them.

The form of this activity allowed for some fun and spontaneous conversation using the vocabulary and grammar that we had been developing over the preceding weeks. Students wore signs indicating the role they were playing (for example Friend or Boss) to emphasize the role-playing nature of the conversation. I listened for grammatical errors that students made in spontaneous speech that they didn’t make in controlled grammar exercises.

This activity enabled the Chinese woman to voice her reserve and receive gentle advice from another student, all in the context of playing a role. This process was very important because it let me hear the issues of concern for this woman: lack of health insurance, language fears, and embarrassment. In addition, the other student was able to give her advice on every point.

It turned out that this woman had not had a check-up since her son had been born five years ago. Our curriculum reflected many of the factors that kept her from getting a check-up and showed her how to get the health care she needed. After completing the cancer unit, we had a week-long break from class. During that time the woman went to a clinic with her cousin who translated for her. She got a Pap smear and had a breast exam that revealed that she had a small lump in her breast. She has scheduled a mammogram and has learned how to do a breast self-exam. I felt very happy that she had taken the initiative to get a check-up as a result of our curriculum.

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Listening
People have a limited tolerance for confronting something as frightening as cancer. I wanted to respect those limits, limits that I actually shared with them. To hear those limits though, one must be listening. This kind of curriculum topic I think demands that the teacher be listening in and out of the classroom, perhaps a little more than usual. I had many conversations with students during this time about their own health fears and concerns. I made it a point to talk with students who seemed especially uncomfortable with the topic. In this way I learned more about the background knowledge and experiences that people brought to this topic. Romona also provided me with insights into the mood of the class and individual students. Bluntly, you can’t just present this information and run.

Also, I found that people’s stories did not come out in a linear fashion. Individuals had different timing. It wasn’t until the second part of our cancer curriculum that a middle-aged Vietnamese man quietly proclaimed his great fear of cancer. His mother had died of breast cancer when he was 4 years old. He was concerned that you could catch cancer from other people and he was very concerned about a possible genetic connection. In response to his situation, I made sure that I found a good article from News For You and some informational brochures from NCI on prostate cancer, which is a common health concern for men of his age. I shared this materials and talked individually with him.

Embarrassment
Embarrassment is something that teachers will hear from their students and perhaps experience for themselves too. Should we abandon information because it is embarrassing? How can we get through the embarrassment? For example, through this curriculum we dealt with parts of the body not usually addressed in an ESL classroom. All those strangely neutered body-part models in ESL texts implicitly let us neglect teaching body parts vocabulary that is in fact much needed by the adult ESL learner, whose health concerns definitely concern those private parts of the body. In fact that was one of the first parts of the unit concerning body parts vocabulary - breast, penis, vagina - and body functions such as menstruation (period and period cramps - which I saw all the women scribble down immediately in their notebooks...), bowel movements, urination... and the more common terminology for all this as well.

I was continually impressed by the generosity of students to respect each other’s embarrassment and soften the awkwardness with jokes and story telling. Embarrassment did not shut the door to this topic. I integrated it into the curriculum and it also took on a cultural note. People acknowledge the openness of U.S. society in talking about this kind of issue. At times, I apologized to people about the embarrassing nature of this topic. But most students, men and women, were emphatic that this topic should be discussed and learned about by both sexes. In fact, one discussion focused on that point. In a model grammar exercise in the form of a true/false quiz, one of the statements was “Men should learn about women’s health issues.” I asked the men first what they thought. The men were from three different countries and of varying ages. All agreed that it was important because they wanted to be able to help the women - wives, girlfriends, mothers, sisters - in their lives.

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Using “Mary’s Story”
My curriculum was really focused on early detection. For people to understand the importance of early detection, they need to learn the whole “story” of the disease. What happens when early detection does not happen?

Mary Walker’s My Life Story With Cancer proved to be a powerful tool in opening up the subject of cervical cancer and in motivating the readers to look at their own health behaviors and attitudes. In order to talk about this subject I had to talk about a woman’s reproductive organs. I used a simple diagram. This proved to cause more embarrassment than talking about breast cancer, mammograms or breast self-exams. Why? I think because the cervix is inside the woman’s body and it is closely related to sex.

One Chinese woman covered the diagram with her hand and found it very difficult to look at. She explained that in China she had not ever talked about this and she really didn’t want to look at it. I apologized that it made her so uncomfortable, but I felt we had to clarify the anatomy of this problem so I plunged ahead with vocabulary building.

This vocabulary didn’t just sit there but was used immediately in the context of understanding Mary’s story. The compelling human aspect of this story helped to shift focus from the talk about embarrassing parts of the body to the specifics of Mary’s experience which reached out to people and made a profound impression on them. Mary’s reluctance to go to the doctor until her pain made her spoke loudly to this group of readers. The support of her family and friends through the ordeal was very important to the class.

I developed some comprehension questions for the story in order to double back and check out what people had understood and what needed to be clarified. However, the crux of the conversation came through exploring two different questions: “What did Mary learn from her experiences?” and “What did you learn from Mary’s experiences?”

Here are some examples of what students wrote:

I think you should visit the doctor for a check-up. If you have a friend who ignores it tell them to go to the doctor.

I learned that when I have some problem with the health I should go to the doctor. When I talk to the doctor I shouldn’t feel shy to talk to the doctor all about my problem.

I learned from Mary’s story that it is necessary to go to the doctor every year for a regular check-up. Also I have to take care of myself and not think that I’m never going to get any serious sickness.

From Mary’s story I learned about cervical cancer. Before I didn’t know about this. I didn’t pay attention to my health about this. But, when I read this story I felt scared and I said to myself that I need to go to see the doctor. I should check-up very often. I should take care of myself. However, I thank Mary because from your story about cancer it helped me know that my health is very important to me. Also it could help me to know that if I ignore my health it might be very dangerous. Mary’s story helped me know more and get more information from her.

A young El Salvadorean man wrote:

I learned that I have to pay attention to my mother and my sister because sometimes my mother doesn’t go to her appointment. I don’t know if she had a mammogram or Pap smear.

Mary’s story helped students look at their own health attitudes and behaviors. One student took it home and shared the story with her teenaged daughter. Her daughter’s response was, “Mami, you have to take care of yourself, go to the clinic to make an appointment for a check-up. It’s a serious problem.” And in fact that student did go have a much needed check-up after we finished with this curriculum unit on cancer.

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Expanding Our Knowledge
As a final piece for this health unit I developed a simple health interview that incorporated many of the health topics that we had talked about from natural remedies and exercise habits to Pap smears and mammogram.
I asked the students to do a health interview with a friend or family member and then write a health story about that person from the interview. I told the men in the class that they didn’t have to interview a woman if they didn’t feel comfortable and that they could ignore the Pap smear, mammogram and breast self-exam questions. Interestingly out of three men only one chose to interview another man.

This interview became an informal assessment tool for me because it enabled me to see what students had understood and retained and what areas they still felt unsure about. We role-played the interview in the classroom. A student interviewed me. Through this process we once again clarified vocabulary and went over Pap smears, mammograms, and breast exams. I asked them what they would do if the person they were interviewing didn’t know what a Pap smear was. Some responded that they could tell them about it! I reassured them that if they didn’t feel comfortable explaining something that they should share the low-literacy fact sheets and brochures that I was handing out with the interview assignment or they could encourage their friends to ask their health practitioner questions.

I had gotten into the topic of cancer by interviewing friends and bringing this vocabulary and health issue actively into my life. I wanted the students to finish this curriculum in the same way. They could assert their “fluency” with these health issues and share their knowledge with their community. As a follow-up to this, I handed out a list of all the vocabulary terms we had encountered. I also asked students to make sentences with the words to assess their fluency.

Health is Life
By the end of the curriculum unit I was convinced of the importance of this material in the ESL classroom and in the lives of my students. If I was developing this unit again, I would trust more and worry less. As one of my students wrote, “I think health is the most important thing in life.” Indeed this curriculum is not just about breast and cervical cancer and early detection - and that is its strength. It is about life. As Ramona, the student consultant, wrote after interviewing her classmates about the curriculum:

Everybody thinks that the classes were very interesting and educational for everybody. People also said that they could learn from these classes, what they can do to make their life better.

I began this curriculum looking at good health. It really came full circle because everyone realized the connection between early detection of breast and cervical cancer and good health. But perhaps most profoundly, everyone embraced how good health leads to a good life.

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Adapted from the Breast and Cervical Cancer Curriculum Sourcebook, pp. 7 - 18, World Education, Boston, MA, 1995.

For copies of My Life Story with Cancer go to the HEAL:BCC Web site at: http://www.worlded.org/us/health/heal or use the HEAL:BCC Publications Order Form included in the HEAL:BCC Teacher Support.